Breast Cancer Surgery Challenging Preconceptions

1. Breast Cancer SurgeryChallenging Preconceptions Hamish Brown Consultant Breast and General Surgeon Sandwell and West Birmingham Hospitals NHS Trust hamish.brown@swbh.nhs.uk

2. Breast Cancer • c46000 new cases per annum • Majority will be treated surgically • Average LOS nationally = 2.62 days • Potential to save at least 65000 bed days • Must be acceptable to patients

3. Reducing length of stay in breast cancer surgery • Conservative surgery • National Screening Program - early detection and small tumours • Axillary sampling v clearance • Sentinel node biopsy • >30% will require mastectomy • Axillary clearance if node positive

4. Length of Stay

5. Why should mastectomy be an in-patient procedure? • Relatively short operation • Low post operative pain • Early mobilisation • No risk of retention/ileus • Rare significant post op events

6. 2006 • We decided to reduce our standard LOS to 23 hours • Process mapping and redesign

7. In patient activities • ‘Pre-operative’ assessment • Psychological needs of patients • Post operative physiotherapy • Temporary prosthesis supply • Discharge by doctors • Take home medications • Wound drain management

8. Surgeon - Consent Anaesthetic Assessment Diagnosis Foundation Year 1 Pre-operative Assessment Preadmission Admit One Day Pre-op Theatre Breast care nurse Exercises/wound care Drain management Post-operative Stay for 4 days Discharge Medications Drain Removal Breast Care Nurse Input Doctor led Discharge after Drain removal

9. Pre-operative assessment • Standardised multidisciplinary pre-op assessment & discharge planning • Surgical care practitioner • (F1 doctor) • Breast Care Nurse • Developed access to specialist assessment • Post op exercises taught • Self management of drains taught • Day of surgery admission • Reduced cancellations/postponements

10. Psychological needs • Assessment by BCN at pre-ad • Psychology assessment very rarely needed • Guaranteed telephone access • Patient satisfaction survey

11. Discharge planning • Take home analgesia at Pre-ad • Follow up appt arranged on admission • Temporary prosthesis supply by ward nurses • Discharge to protocol by ward nurses • Out patient review by BCN at 3 days • No Primary care involvement or workload

12. Diagnosis Preadmission Admit One Day Pre-op Theatre Post-operative Stay for 4 days Doctor led Discharge after Drain removal HistoricPathway Integrated Care Pathway Diagnosis FY 1 Anaesthetic Assessment SCP /FY1 Anaesthetic Assessment TTO Drain Education, ED Planning (BCN) Preadmission Anaesthetic Assessment Surgeon – Consent Surgeon - Consent Admit Day ofSurgery Theatre TTO BCN input Nurse led discharge Same day or 23 hours Day 3 Follow-up by BCN for wound check and drain removal

13. Pilot Study -Identified problems • Patient lack of confidence – drains • Over-proscriptive guidelines • Nausea and vomiting • Bed availability & delays • At end of pilot average LOS = 2 days • Minor complaints • 28 day emergency readmission 1%

14. Birmingham (NHS)Treatment Centre

15. Change of Approach • Sentinel node biopsy = 50% reduction in traditional IP caseload • Treatment Centre admission by preference • Review of drain use • Default to day case

16. The results

19. Conclusions • Breast cancer surgery can safely be carried out as 23 hr stay or day case. • Wound drains can be managed by patients at home. • Wound drains make little difference to seroma rates. • Integrated pre-operative assessment is key to reducing length of stay.

20. British Association of Day Surgery

21. Spreading the learning • Possible to do in other tumour sites? • Appropriate length of stay • Similar issues • How? • Who will benefit?